今日の臨床サポート

高齢者虐待

著者: 山中俊祐 福井大学医学部附属病院 救急部

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/02/17

概要・推奨   

  1. 虐待されている高齢者はその心理的、財政的、社会的な状況により、虐待の事実を否定する傾向がある。また虐待に対する自覚は当てにならない。
  1. 身体的、性的な虐待以外にも、ネグレクト、経済的、心理的虐待の可能性も考える。
  1. 高齢者虐待に典型的な皮膚所見を知っておく。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山中俊祐 : 研究費・助成金など(福井県「新型コロナウイルス感染症研究推進事業」,福田記念医療技術振興財団)[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. 定期レビューを行い、厚生労働省発表の数値を追加した。

まとめ

まとめ  
  1. 高齢者虐待とは「養護者や養介護施設の従事者による65歳以上の者に対する虐待」であり、
  1. 身体的虐待
  1. ネグレクト(著しい減食・放置、養護者以外の同居人による虐待行為の放置を含む)
  1. 心理的虐待
  1. 性的虐待
  1. 経済的虐待(親族らによる高齢者の財産を不当に処分し、財産上の利益を得ること)
からなる。
  1. 多くの医師がその重要性にもかかわらず、高齢者虐待に関して知識が不足し、過小評価し、適切な評価、対処の仕方がわからないでいる。
  1. 日本における高齢者虐待の構成割合は身体的虐待(74.8%)心理的虐待(37.1%)ネグレクト(10.6%)性的虐待(4.0%)経済的虐待(2.6%)となっている[1]
  1. 先進国の疫学調査では7.6~10.0%の高齢者が虐待され、認知症を患っている高齢者では身体的虐待が11%、心理的虐待が19%との報告があり、高齢者虐待は全世界的な問題となっている[2]
  1. 高齢者虐待は医学的、社会的、倫理的、法律的そして財政的なサポートなどの多様な援助が必要であり、医師1人で対処するのは困難であることが多い。医師、看護師、ソーシャルワーカー、公的機関の専門家、弁護士、介護士などの多種にわたる専門チームを作って個別に対処するのが望ましい。
  1. 高齢者虐待は適切な対処をせずに放置すると3年以内の死亡率が3.1倍上昇する予後が悪い進行性の急性疾患である(13年間の追跡調査では虐待されていないお年寄りの生存率が41%であったのに対して、虐待を受けていたお年寄りの生存率はわずか9%であったとの報告もある)[3]
  1. 2011 年度の養護者による高齢者虐待に関する相談・通報件数は、25,636 件であり、養介護施設従事者などによる高齢者虐待に関する相談・通報件数は、687 件であり、養護者による被養護者の虐待(ネグレクトなどすべての虐待形態を含む)は21件であった。2017年には養護者による高齢者虐待に関する相談・通報件数が26,668件、養介護施設従事者などによる高齢者虐待に関する相談・通報件数も1,640 件と増加傾向にあり、それ以後も増加していると思われる。
  1. 有病率が4~10%程度とされる一般的な疾患であると認識すべきであり、市町村への通報まで至るものは非常に限られた数でしかない[4][5]
  1. 75歳以上、女性、認知症、うつ、精神病、アルコール中毒、要介護3以上などは高齢者虐待のリスクである。
  1. 身体的虐待で最も多い部位は顔面(32%)、首(15%)、顎(11%)であり、頚部より上部の外傷では常に念頭におく[6]
  1. 高齢者虐待に及ぶ者のほとんどが一緒に住んでいる家族であり、医療機関のスタッフが唯一の虐待に関与していない第三者である場合がある。
  1. 虐待されている高齢者はその典型的な心理状況により、虐待の事実を否定する傾向もある。虐待に対する自覚は当てにならない。
  1. 虐待されている高齢者を発見した場合は、その安全と保護を第一に対応すべきであり、できる限り公的な関係機関との連携を行う。高齢者虐待を認めた場合は2006年4月1日に施行された「高齢者虐待の防止、高齢者の養護者に対する支援等に関する法律」に定めるところにより速やかに市町村に報告するよう努めなくてはならない。
  1. 救急外来は高齢者虐待を拾い上げる貴重な機会となり得るが、多くの臨床医は高齢者虐待への知識不足、訓練不足、忙しさ、また高齢者虐待と判明した時の追加の業務への懸念などから、高齢者虐待診断へのハードルは高い。多職種連携が必須となる[7]
  1. 地域包括支援センターが構築する「高齢者虐待防止ネットワーク」を活用することが有効である。
  1. 虐待に対する患者の「自覚」は必要ではない。
  1. 高齢者の安全確保が最優先。
  1. 組織として、チームとして行動し個人で問題に当たらない。
  1. 素早い対応を心がける。
  1. 適切に権限を行使することを躊躇しない。
  1. 認知症の重症度が軽度に収まるなら、虐待の医療者などへの自己申告は可能であり、軽視すべきでない[8]

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: Éric Mercier, Alexandra Nadeau, Audrey-Anne Brousseau, Marcel Émond, Judy Lowthian, Simon Berthelot, Andrew P Costa, Fabrice Mowbray, Don Melady, Krishan Yadav, Christian Nickel, Peter A Cameron
雑誌名: Ann Emerg Med. 2020 Feb;75(2):181-191. doi: 10.1016/j.annemergmed.2019.12.011.
Abstract/Text This scoping review aimed to synthesize the available evidence on the epidemiology, patient- and caregiver-associated factors, clinical characteristics, screening tools, prevention, interventions, and perspectives of health care professionals in regard to elder abuse in the out-of-hospital or emergency department (ED) setting. Literature search was performed with MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library. Studies were eligible if they were observational or experimental and reported on elder abuse in the out-of-hospital or ED setting. A qualitative approach, performed independently by 2 reviewers, was used to synthesize and report the findings. A total of 413 citations were retrieved, from which 55 studies published between 1988 and 2019 were included. The prevalence of elder abuse reported during the ED visit was lower than reported in the community. The most commonly detected type of elder abuse was neglect, and then physical abuse. The following factors were more common in identified cases of elder abuse: female sex, cognitive impairment, functional disability, frailty, social isolation, and lower socioeconomic status. Psychiatric and substance use disorders were more common among victims and their caregivers. Screening tools have been proposed, but multicenter validation and influence of screening on patient-important outcomes were lacking. Health care professionals reported being poorly trained and acknowledged numerous barriers when caring for potential victims. There is insufficient knowledge, limited training, and a poorly organized system in place for elder abuse in the out-of-hospital and ED settings. Studies on the processes and effects of screening and interventions are required to improve care of this vulnerable population.

Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID 31959308  Ann Emerg Med. 2020 Feb;75(2):181-191. doi: 10.1016/j.a・・・
著者: XinQi Dong
雑誌名: Clin Geriatr Med. 2005 May;21(2):293-313. doi: 10.1016/j.cger.2004.10.006.
Abstract/Text Recognition of elder abuse and neglect among health care professionals has been a relatively recent phenomenon. Each year, millions of elderly persons suffer as the result of abuse and neglect. Their quality of life is severely jeopardized in the form of worsened functional status and progressive dependency, poorly rated self-health, feelings of helplessness, and from the vicious cycle of social isolation, stress and further psychologic decline. Other medical implications of abuse and neglect include higher health systems use in the form of frequent ER visits, higher hospitalization, and higher nursing home placement; most importantly, it is an independent predictor for higher mortality. Physicians are well situated in detecting and reporting suspected cases and taking care of the frail elders who are victims of abuse and neglect, but there are barriers on the individual level, and there is a broader need for system change. Through education, training, and reinforcement, there are strategies to get health care professionals more involved and provide effective management protocols and guidelines for us to advocate for our patients in the current epidemic of elder abuse and neglect.

PMID 15804552  Clin Geriatr Med. 2005 May;21(2):293-313. doi: 10.1016/・・・
著者:
雑誌名: 2014 Mar 15;89(6):453-60.
Abstract/Text
PMID 24695564  2014 Mar 15;89(6):453-60.
著者: Tony Rosen, Veronica M LoFaso, Elizabeth M Bloemen, Sunday Clark, Thomas J McCarthy, Christopher Reisig, Kriti Gogia, Alyssa Elman, Arlene Markarian, Neal E Flomenbaum, Rahul Sharma, Mark S Lachs
雑誌名: Ann Emerg Med. 2020 Sep;76(3):266-276. doi: 10.1016/j.annemergmed.2020.03.020. Epub 2020 Jun 10.
Abstract/Text STUDY OBJECTIVE: Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls.
METHODS: We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to 2014.
RESULTS: We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%).
CONCLUSION: Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.

Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID 32534832  Ann Emerg Med. 2020 Sep;76(3):266-276. doi: 10.1016/j.a・・・
著者: Tony Rosen, Michael E Stern, Mary R Mulcare, Alyssa Elman, Thomas J McCarthy, Veronica M LoFaso, Elizabeth M Bloemen, Sunday Clark, Rahul Sharma, Risa Breckman, Mark S Lachs
雑誌名: Emerg Med J. 2018 Oct;35(10):600-607. doi: 10.1136/emermed-2017-207303. Epub 2018 Aug 9.
Abstract/Text BACKGROUND: An ED visit provides a unique opportunity to identify elder abuse, which is common and has serious medical consequences. Despite this, emergency providers rarely recognise or report it. We have begun the design of an ED-based multidisciplinary consultation service to improve identification and provide comprehensive medical and forensic assessment and treatment for potential victims.
METHODS: We qualitatively explored provider perspectives to inform intervention development. We conducted 15 semistructured focus groups with 101 providers, including emergency physicians, social workers, nurses, technologists, security, radiologists and psychiatrists at a large, urban academic medical centre. Focus groups were transcribed, and data were analysed to identify themes.
RESULTS: Providers reported not routinely assessing for elder mistreatment and believed that they commonly missed it. They reported 10 reasons for this, including lack of knowledge or training, no time to conduct an evaluation, concern that identifying elder abuse would lead to additional work, and absence of a standardised response. Providers believed an ED-based consultation service would be frequently used and would increase identification, improve care and help ensure safety. They made 21 recommendations for a multidisciplinary team, including the importance of 24/7 availability, the value of a positive attitude in a consulting service and the importance of feedback to referring ED providers. Participants also highlighted that geriatric nurse practitioners may have ideal clinical and personal care training to contribute to the team.
CONCLUSIONS: An ED-based multidisciplinary consultation service has potential to impact care for elder abuse victims. Insights from providers will inform intervention development.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
PMID 30093378  Emerg Med J. 2018 Oct;35(10):600-607. doi: 10.1136/emer・・・
著者: Natalie L Richmond, Sheryl Zimmerman, Bryce B Reeve, Joseph A Dayaa, Mackenzie E Davis, Samantha B Bowen, John A Iasiello, Rachel Stemerman, Rayad B Shams, Jason S Haukoos, Philip D Sloane, Debbie Travers, Laura A Mosqueda, Samuel A McLean, Timothy F Platts-Mills
雑誌名: J Am Geriatr Soc. 2020 Jan;68(1):170-175. doi: 10.1111/jgs.16211.
Abstract/Text OBJECTIVES: To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)-based screen for elder abuse.
DESIGN: Cross-sectional study in which participants were screened for elder abuse and neglect.
SETTING: Academic ED in the United States.
PARTICIPANTS: Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses.
MEASUREMENTS: All patients completed the four-item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients.
RESULTS: Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5).
CONCLUSIONS: In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170-175, 2019.

© 2020 The American Geriatrics Society.
PMID 31917460  J Am Geriatr Soc. 2020 Jan;68(1):170-175. doi: 10.1111/・・・
著者: Timothy F Platts-Mills, Karen Hurka-Richardson, Rayad B Shams, Aileen Aylward, Joseph A Dayaa, Melinda Manning, Laura Mosqueda, Jason S Haukoos, Mark A Weaver, Philip D Sloane, Debbie Travers, Phyllis L Hendry, Ashley Norse, Christopher W Jones, Samuel A McLean, Bryce B Reeve, Sheryl Zimmerman, Investigators for the ED Senior AID Research Group, Katie Davenport, Debra Bynum, Emilia Frederick, Kim Lassiter-Fisher, Amy Stuckey, Racquel Daley-Placide, Mark Hoppens, Judy Betterton, Samantha Owusu, Cynthia Flemming, Andrew Colligan
雑誌名: Ann Emerg Med. 2020 Sep;76(3):280-290. doi: 10.1016/j.annemergmed.2020.07.005.
Abstract/Text STUDY OBJECTIVE: Emergency department (ED) visits provide an important opportunity for elder abuse identification. Our objective was to assess the accuracy of the ED Senior Abuse Identification (ED Senior AID) tool for the identification of elder abuse.
METHODS: We conducted a study of the ED Senior AID tool in 3 US EDs. Participants were English-speaking patients 65 years old and older who provided consent or for whom a legally authorized representative provided consent. Research nurses administered the screening tool, which includes a brief mental status assessment, questions about elder abuse, and a physical examination for patients who lack the ability to report abuse or for whom the presence or absence of abuse was uncertain. The reference standard was based on the majority opinion of a longitudinal, expert, all data (LEAD) panel following review and discussion of medical records, clinical social worker notes, and a structured social and behavioral evaluation. For the reference standard, LEAD panel members were blinded to the results of the screening tool.
RESULTS: Of 916 enrolled patients, 33 (3.6%) screened positive for elder abuse. The LEAD panel reviewed 125 cases: all 33 with positive screen results and a 10% random sample of negative screen results. Of these, the panel identified 17 cases as positive for elder abuse, including 16 of the 33 cases that screened positive. The ED Senior AID tool had a sensitivity of 94.1% (95% confidence interval [CI] 71.3% to 99.9%) and specificity of 84.3% (95% CI 76.0% to 90.6%).
CONCLUSION: This multicenter study found the ED Senior AID tool to have a high sensitivity and specificity as a screening tool for elder abuse, albeit with wide CIs.

Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID 32828327  Ann Emerg Med. 2020 Sep;76(3):280-290. doi: 10.1016/j.a・・・
著者: Mark J Yaffe, Christina Wolfson, Maxine Lithwick, Deborah Weiss
雑誌名: J Elder Abuse Negl. 2008;20(3):276-300. doi: 10.1080/08946560801973168.
Abstract/Text This study aimed to develop and validate a brief tool for physician use to improve suspicion about the presence or absence of elder abuse. A literature review on elder abuse, obstacles to its identification, limitations of detection tools, and characteristics of screeners employed by physicians were used to generate elder abuse detection questions for critique by 31 doctors, nurses, and social workers in focus groups. Six resulting questions became the Elder Abuse Suspicion Index (EASI) administered by 104 family doctors to 953 cognitively intact seniors in ambulatory-care settings. Findings were compared to a recognized, detailed elder abuse Social Work Evaluation (SWE) later administered to participants by social workers blinded to the results of the EASI. The EASI had an estimated sensitivity and specificity of 0.47 and 0.75, usually took less than 2 minutes to ask, and 97.2% of doctors felt it would have some or big practice impact. This research is a first phase in the development and validation of a user-friendly tool that might sensitize physicians to elder abuse and promote referrals of possible victims for in-depth assessment by specialized professionals.

PMID 18928055  J Elder Abuse Negl. 2008;20(3):276-300. doi: 10.1080/08・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから